HomeMy WebLinkAboutSWG95-00767 - SWG Application / As-Built - 11/6/1995 ON-SITE SEWAGE SYSTEM SITE EVALUATION AND DISPOSAL PERMIT
ASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG 95- c H
426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 D 5. H
ata I S N. H
PHONE (360) 427-9670 Amount$Receipt No. LSC1 'o i V
PHY&T OWNER:
v m
Gac.la �n-a 9 CHECK APPLICABLE ITEMS ✓ m `m
MAILING A ORE S: DAYTIME PHONE: NEW SYSTEM W o
t.
'� REPAR SYSTEM rg_
CITY: seaf fI — STATE:W� ZIP:f� MAINTENANCE REVIEW d
(� SINGLE FAMILY x 8
PROPERTY ADDRESS: OTHER -( z
SPECIFY: `
SPECIFIC DIR CTIONS FOR LOCATING SITE: PRIVATE WELL
56FL ZIP COMMUNITY WELLPUBLIC SYSTEM
SYSTEM WFHf t
SYSTEM NAME �.
APPLICANT to
NAME 7r !VIC 9.I
Name of , p Lot MAILING ADDRESS •0 ZS -
Installer �LV tl r G�
Size: acres TELEPHONE b Z —
Nameof um ero SIGNATURE— /}-1 :Z0
Designer '' II '
h'1� ' Bedrooms X
9
PLOT PLAN w
�^-Drew a dimensional plot plan,
including: z as 1
o
❑Precise OC8o0 Of test
holes,showing q o Q
measured distances to
property boundaries. 4�
❑Entry road; rff% i C. y _
driveways. p)
I1Nn�} •s •w
NOTE: DO DRAW IN �
SYSTEM DESIGN, 0 3 10 n
IY U Y 1,77J
{ D I NOT WRITE BELOW DOUBLE LINE.
SOIL LOGS
Tot /H d_56 r �rHz-0-3e" II tda r ,&.«S , /4/'r A 310 0J! f fOG21`E t 3
N
018 O-!e0{ Sa 7-HZ-0-f° ,Saved tQrofs /,r 5
3d G S6{ IB LS ,66121�2� Qt �3S` A&5 o-��N•<aar) lmv
iv vel'3p-?$" /,6 lour, 5,vz / en �20?� slPr
' /O 4S 5 on �Ilj/g $-/ Depth from Original
a� 5 on om s1 �?t�
an v� ca Grade to Restrictive 16�C 641n/ /" l0 b v) !O / Layer or Water Table: n.
DESIGNER DESIGNATION SCORES L 6 I'r'/ NIMUM SYSTEM REQUIREMENTS
Fi In Score C/ Designer Level: (gone ❑TWO
Soil Type
Vertical Separetion� In. o Septic Tank Daily 9
Capacity: /15o' Gal. Flow: J60 GPD
Slope Appl. Infilt.
Parcel Size /,,7 AS 40 Rate 0, 5' GPD/FT' Area SQ Ff'
Distance to Shoreline On. _� Total Inspector Date
11 15'OYI-
COMMENTSIC ND T NSF R APPR
/ hat ' a
l
•All septic systems must be esigned and installed by contractors certified by Ma6Vn Couo Department Health 9firvices,unless prior approval is
granted by the department,or the design is by a professional engineer.
•Septic permit approval does not imply other building site requirements(i.e. RLC,Water Adequacy)have been met.
•Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit.
•This perm' 'res 2 years from the date of she review.Denial of this perm' may be appealed to a Health Officer within 10 days of denial date.
SIT E I DESIG REV V+�: Approved jNotA pr ed INSTALLATION:O Approved 0Not Approved
BY. DATE: BY
DATE BY: DATE:
TOP: Health Dept.Copy M LE: Designer's Copy BOTTOM:Applicant's Copy
AS-BUILT FORM - PAGE TWO Mvleed 11/14/9e
II ` PARCEL IDENTIFICATION
II Applicant's Name �G
Permit Number SWG9 Subdivision
II —f IItp
� / ame lvl 1 0 Installer's Name ^F kt r,�ro Assessor's Parcel No.
�Tweive-uigxt VuMerT
II Designer's Name
II AS-BUILT DRAWING
I
II
II
II
II
I
I
II
b �
x
�I k 2 3 u
N M1
II �
N n
s E Ok
CA y ,
u � o I % )c Fur -q-law-s
sc
did
r
f wnw: Minor adjustments to ptle tad+ iota[lm end drai £leis drl en[a[ion suds to Me field by the instatler ate generally an
eeptable to both the deptteent end the d<eJV-t, but to-ld 1. certoln cases �—i-- the Weblllty of the -let- Ic ie to
1nB[aller'a reepanelblllty to obtain prior vrltten gyrowl fray el Cher the h_ith denrement or ae deafgner before making en
davL ti ens [ram tha dealgn Nat affect e,,tee vlablllty. My devletlona from the eppanved deelgn meet be ah. ebove.
N �/( AS-BUILT CHECKLIST
Drainfield orientation Observation port location X Undisturbed native soil
and layout between trenches
Cleanout location f�
�renCh/bed dimensions and W North arrow
N critical distances within 6 Manifold placement
layout t} Scale of drawing Shown
N `Cm Orifice placement on scale bar
N D-Box/"T"/"L" location �y
u � Lateral placement, with Additional Mound Information
septic tank/pump chamber distances to edge of bed r, I
location f'y u Endslope width
> Location of wells, roads ElII Location of buildings Overall fill dimensions
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